Chronic Low Back Pain in Old Age – Symptoms, Treatment

Chronic Low Back Pain in Old Age/Chronic Low Back Pain is defined as pain that continues for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. Even if pain persists, it does not always mean there is a medically serious underlying cause or one that can be easily identified and treated. In some cases, treatment successfully relieves chronic low back pain, but in other cases, pain continues despite medical and surgical treatment.

Chronic low back pain (CLBP) is the most common musculoskeletal condition affecting the adult population, with a prevalence of up to 84%. Chronic LBP (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 12 weeks . Many authors suggest defining chronic pain as pain that lasts beyond the expected period of healing, avoiding this close time criterion. This definition is very important, as it underlines the concept that CLBP has well-defined underlying pathological causes and that it is a disease, not a symptom. CLBP represents the leading cause of disability worldwide and is a major welfare and economic problem .

Chronic Back Pain is pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica), and is defined as chronic when it persists for 12 weeks or more. Non-specific low back pain is pain not attributed to a recognizable pathology (such as infection, tumor, osteoporosis, rheumatoid arthritis, fracture, or inflammation). People in this review have chronic low back pain (>12 weeks’ duration).

Types of Pain

There are multiple categories and types of pain, including neuropathic, nociceptive, musculoskeletal, inflammatory, psychogenic, and mechanical.

Neuropathic pain

  • Peripheral neuropathic pain as the case post-herpetic neuralgia or diabetic neuropathy
  • Central neuropathic pain – cerebral vascular accident sequella

Nociceptive pain

  • Pain due to actual tissue injuries such as burns, bruises, or sprains

Musculoskeletal pain

  • Back pain
  • Myofascial pain

Inflammatory pain

  • Autoimmune disorders (rheumatoid arthritis)
  • Infection

Psychogenic pain

  • Pain caused by psychologic factors such as headaches or abdominal pain caused by emotional, psychological, or behavioral factors

Mechanical pain 

  • Expanding malignancy

Causes of Chronic Low Back Pain in Old Age

Most Chronic low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move. Some examples of mechanical causes of low back pain include:

  • Skeletal irregularities – such as scoliosis (a curvature of the spine), lordosis (an abnormally exaggerated arch in the lower back), kyphosis (excessive outward arch of the spine), and other congenital anomalies of the spine.
  • Spina bifida – involves the incomplete development of the spinal cord and/or its protective covering and can cause problems involving malformation of vertebrae and abnormal sensations and even paralysis.
  • Sprains – (overstretched or torn ligaments), strains (tears in tendons or muscle), and spasms (sudden contraction of a muscle or group of muscles)
  • Traumatic injury – such as from playing sports, car accidents, or a fall that can injure tendons, ligaments, or muscle causing the pain, as well as compress the spine and cause discs to rupture or herniate.
Degenerative problems
  • Intervertebral disc degeneration – occurs when the usually rubbery discs wear down as a normal process of aging and lose their cushioning ability.
  • Spondylosis – the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older.
  • Arthritis or another inflammatory disease – in the spine, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae.
  • Disc prolapse and radiculopathy
  • Spinal stenosis and pseudo claudication
  • Cauda equina syndrome
Nerve and spinal cord problems
  • Spinal nerve compression, inflammation, and/or injury
  • Sciatica – (also called radiculopathy), caused by something pressing on the sciatic nerve that travels through the buttocks and extends down the back of the leg. People with sciatica may feel shock-like or burning low back pain combined with pain through the buttocks and down one leg.
  • Spinal stenosis – the narrowing of the spinal column that puts pressure on the spinal cord and nerves
  • Spondylolisthesis – which happens when a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column
  • Herniated or ruptured discs  – can occur when the intervertebral discs become compressed and bulge outward
  • Infections – involving the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis
  • Cauda equina syndrome – occurs when a ruptured disc pushes into the spinal canal and presses on the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
  • Osteoporosis – (a progressive decrease in bone density and strength that can lead to painful fractures of the vertebrae)
Non-spine sources
  • Kidney stones can cause sharp pain in the lower back, usually on one side
  • Endometriosis (the buildup of uterine tissue in places outside the uterus)
  • Fibromyalgia (a chronic pain syndrome involving widespread muscle pain and fatigue)
  • Tumors that press on or destroy the bony spine or spinal cord and nerves or outside the spine elsewhere in the back
  • Pregnancy (back symptoms almost always completely go away after giving birth)
  • Rheumatologic – ankylosing spondylitis, Reiter syndrome, psoriatic spondylitis, polymyalgia rheumatica
  • Oncologic – metastatic disease, spinal cord tumor, lymphomas, leukemia, multiple myeloma
  • Infectious – spinal epidural abscess, osteomyelitis, discitis
  • Gastrointestinal – pancreatitis, cholecystitis, bowel perforation
  • Vascular – aortic aneurysm, spinal epidural hematoma, aortoiliac disease
  • Renal – pyelonephritis, nephrolithiasis, perinephric abscess
  • Genitourinary – endometriosis, prostatitis, pelvic inflammatory disease
  • Spinal foraminal stenosis
  • Herniated discs
  • Spinal stenosis
  • Degenerative disc disease
  • Vertebral fractures
  • Sacroiliac joint dysfunction
  • Facet joint syndrome
  • Ligamentous and muscular injury
  • Myofascial pain syndrome

Spine Related Causes


  • Sprains and strains
  • Fractures


  • Spondyloarthropathy


  • Metastatic disease
  • Intramedullary tumor


  • Spondylodiscitis
  • Vertebral osteomyelitis

Non-spine Related

  • Aortic disease dissection,  aneurysm,
  • Genitourinary disease – Colic, tumor, and infection.
  • Gastrointestinal causes – pancreatitis and pancreatic cancer, peptic ulcer, cholecystitis, and cholangitis

Symptoms of Chronic Low Back Pain in Old Age

Chronic low back pain symptoms are

  • Pain in the back, and sometimes all the way down to the buttocks and legs. Some back issues can cause pain in other parts of the body, depending on the nerves affected.
  • In most cases, signs, and symptoms clear up on their own within a short period. If any of the following signs or symptoms accompany back pain, people should see their doctor:
  • Pain. It may be continuous, or only occur when you are in a certain position. The pain may be aggravated by coughing or sneezing, bending or twisting.
  • Patients who have been taking steroids for a few months
  • Drug abusers
  • Patients with cancer
  • Patients who have had cancer
  • Patients with depressed immune systems
  • Stiffness.
  • Thoracic pain
  • Fever/unexplained weight loss
  • Night sweats
  • Bowel or bladder dysfunction
  • Malignancy (document/record any previous surgeries, chemo/radiation, recent scans and bloodwork, and history of metastatic disease)
    • Can be seen in association with pain at night, pain at rest, unexplained weight loss, or night sweats
  • Significant medical comorbidities
  • Neurologic deficit or serial exam deterioration
  • Gait ataxia
  • Saddle anesthesia

Red flag conditions indicating possible underlying spinal pathology or nerve root problems

Red flags

  • Onset age < 20 or > 55 years
  • Non-mechanical pain (unrelated to time or activity)
  • Thoracic pain
  • Previous history of carcinoma, steroids, HIV
  • Feeling unwell
  • Weight loss
  • Widespread neurological symptoms
  • Structural spinal deformity

Indicators for nerve root problems

  • Unilateral leg pain > low back pain
  • Radiates to foot or toes
  • Numbness and paraesthesia in the same distribution
  • Straight leg raising test induces more leg pain
  • Localized neurology (limited to one nerve root)

Diagnosis of Chronic Low Back Pain in Old Age

The physical examination should include assessment of symmetry in both the sagittal and coronal plane, gait, muscle atrophy, flexibility (flexion, extension, lateral flexion and rotation), touch and pinprick sensation in all relevant dermatomes, muscle power, deep tendon reflexes, Babinski, clonus, tenderness, straight leg raising, femoral stretch test and FABER’s test .

The majority of low back pain do not have an identifiable diagnosis.  Also, the standard battery of tests during the physical examination may not identify the strength and endurance of the paraspinal muscles, which plays a significant role in low back pain.  The following tests could identify the weakness in these muscles

  • A straight leg raising – can be painful in lumbosacral radiculopathy. The mechanism of pain during a straight leg raise is increased dural tension placed upon the lumbosacral spine during the test. Patients are supine during the test. The physician will flex the patient’s quadriceps with the leg in extension as well as dorsiflex the patient’s foot on the symptomatic side. Pain or reproduction of paresthesias is considered a positive test (Lasegue sign). Separately, a Bowstring sign is a relief of this underlying radicular pain with flexion of the patient’s knee on the affected side. The straight leg raising test is most helpful in the diagnosis of L4 and S1 radiculopathies.
  • An internal hamstring reflex – for L5 radiculopathy has also been shown to be a useful test. Tapping either the semimembranosus or the semitendinosus tendons proximal to the popliteal fossa elicits the reflex. When there is an asymmetry of the reflex between legs, this can be significant for radiculopathy.
  • A contralateral straight leg raising test – is the passive flexion of the quadriceps with the leg in extension and foot in dorsiflexion of the unaffected leg by the physician. This test is positive when the unaffected leg reproduces radicular symptoms in the patient’s affected limb. However, the straight leg raising test is more sensitive but less specific than the contralateral straight leg raising test.
  • The prone instability test – The patient starts by standing on one end of the examination couch. While continuing to stand on the foot end of the couch, the patient lowers his / her torso onto the couch.  The patient can hold onto the couch’s sides for support. The examiner then palpates the lower lumbar spine to elicit tenderness. The patient then holds onto the couch and lifts his / her feet off the ground tensing the paraspinal muscles. Less pain and tenderness on repeat palpation of the lower lumbar spine, while the feet are off the floor, is considered positive.
  • Prone Plank/Bridge – The patient is prone and elevates his / her entire body off the couch/mat on the forearms and tips of toes. The body should be parallel to the couch/mat. With adequate muscle strength, men should maintain this position for 124 +/- 72s and Women for 83 +/- 63s.
  • Supine Bridge – The patient is supine and flexes the hip and knee to keep the feet flat on the couch/mat. The arms are flexed to position the hands beside the ears. The lower part of the torso and pelvis is lifted off the couch/mat, to maintain the trunk and the thigh in a straight line. With adequate muscle strength, men should maintain this position for 188 +/- 45s and Women for 152 +/- the 30s.

Tests include

  • Blood tests – are not routinely used to diagnose the cause of back pain but might be ordered to look for signs of inflammation, infection, cancer, and/or arthritis.
  • Bone scans – can detect and monitor an infection, fracture, or bone disorder. A small amount of radioactive material is injected into the bloodstream and collects in the bones, particularly in areas with some abnormality. Scanner-generated images can identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
  • Discography – involves injecting a contrast dye into a spinal disc thought to be causing low back pain. The fluid’s pressure in the disc will reproduce the person’s symptoms if the disc is the cause. The dye helps to show the damaged areas on CT scans taken following the injection.

Electrodiagnostics can identify problems related to the nerves in the back and legs. The procedures include:

  • electromyography (EMG) – assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body.
  • evoked potential studies – involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal transmissions to the brain.
  • nerve conduction studies (NCS) – also use two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage.


  • X-rays – These are very accessible at most clinics and outpatient offices. This imaging technique can be used to assess for any structural instability. If x-rays show an acute fracture, it needs to be further investigated using a computed tomogram (CT) scan or magnetic resonance imaging (MRI).
  • CT Scan – It is the preferred study to visualize bony structures in the spine. It can also show calcified herniated discs. It is less accessible in office settings compared to x-rays. But it is more convenient than MRI. In the patients that have non-MRI comparable implanted devices, CT myelography can be performed to visualize herniated disc.
  • CT myelography – is when the patient has either a contraindication to having an MRI such as having a pacemaker device or defibrillator or be used when a standard CT or MRI is negative or equivocal. Myelography is a CT scan or an MRI with intrathecal administration of contrast. CT myelography visualizes a patient’s spinal nerve roots in their passage through the neuroforamina. CT myelography can be used to assess the underlying root sleeve. A unique population to recommend a CT myelogram is for patients with surgical spinal hardware. A CT is a poor test for the visualization of nerve roots, making it challenging to diagnose radicular disease.
  • Electromyography (EMG) – are complete after three weeks of symptoms, not before. Diagnostic tests such as EMG or nerve conduction studies are accurate only after three weeks of persistent symptoms. The primary reason why ordering an EMG or nerve conduction study is delayed three weeks following the development of pain is because fibrillation potentials after an acute injury lead to an axonal motor loss. These do not develop until two to three weeks following injury.
  • Cerebrospinal fluid analysis – is a useful test if there is a suspected neoplasm or infectious cause or radiculopathy symptoms. The recommendation for a lumbar puncture is in the case of a patient with negative or nondiagnostic neuroimaging, without known primary cancer, who has progressive neurological symptoms and has failed to improve promptly.
  • MRI – It is the preferred and most sensitive study to visualize herniated disc. MRI findings will help surgeons and other providers plan procedural care if it is indicated.
  • Bone scintigraphy – with single-photon emission computed tomography (SPECT) is more sensitive in detecting facet joint lesions and allows more accurate anatomical localization. A recent study suggested that SPECT could help to identify patients with low back pain who would benefit from facet joint injections []. Facet joint block (FJB) is an indispensable diagnostic instrument in order to distinguish painful from painless facet joints, and to plan the intervention strategy.
  • Foraminal nerve root entrapment test – is best visualized on T1-weighted MRI where the high contrast between fat tissue and the nerve root sheath is of great help. Usually, a combination of hypertrophic degenerative facets with osteophytes spurs posteriorly, and vertebral osteophytes and/or disc herniation anteriorly diminishes the anteroposterior diameter of the foramen. Foraminal height is lessened by degenerative disc disease and subsequent disc height loss. Whenever the normal rounded (oval) appearance of the nerve root sheath is lost in combination with loss of the surrounding fat tissue, nerve root compression should be considered.

Treatment of Chronic Low Back Pain in Old Age

Patient Education

  • Use of hot or cold packs for comfort and to decreased inflammation
  • Avoidance of inciting activities or prolonged sitting/standing
  • Practicing good, erect posture
  • Engaging in exercises to increase core strength
  • Gentle stretching of the lumbar spine and hamstrings
  • Regular light exercises such as walking, swimming, or aromatherapy
  • Use of proper lifting techniques


For chronic low back pain, non-pharmacologic approaches were recommended as the first-line agents, including exercise, tai-chi, yoga, multidisciplinary rehabilitation, spinal manipulation, acupuncture, psychotherapy, low-level laser therapy, and electromyogram biofeedback.

Broadly speaking the treatments that have been used for non-specific low back pain are:

  • Basic Information – Including advice from practitioners regarding exercise and/or causes of back pain, formal education sessions, and written educational material.
  • Physiotherapy – Physiotherapy aims to improve human function and movement and maximizing potential: it uses physical approaches to promote, maintain and restore physical, psychological, and social well-being, through the use of manual therapy, electrotherapy, and exercise.
  • Manual therapies – including manipulation, massage, mobilization.
  • Other non-pharmacological interventions – Including, laser, transcutaneous electrical nerve stimulation, traction, ultrasound, IRR, wax therapy.
  • Back school – These include the components seen in some types of back school and multidisciplinary rehabilitation programs
  • Percutaneous electrical nerve stimulation (PENS)- including acupuncture, electro-acupuncture, nerve blocks, neuro reflexotherapy, percutaneous electrical nerve stimulation (PENS), injection of a therapeutic substance into the spine.
  • Hydrotherapy – An exercise treatment conducted within a specially designed pool so that water supports the patient’s body weight
  • Interferential therapy – An electrical treatment that uses two medium frequency currents, simultaneously, so that their paths cross. Where they cross a beat frequency is generated which mimics a low-frequency stimulation
  • Intra-Discal Electrothermal Therapy (IDET) – Use of a heating wire passed through a hollow needle into the lumbar disc intended to seal any ruptures in the disc.
  • Lumbar supports – External devices designed to reduce spinal mobility, e.g. corsets
  • Manipulation – Small amplitude high-velocity movement at the limit of joint range taking the joint beyond the available range of movement.
  • Transcutaneous electrical nerve stimulation (TENS) – Electrodes are placed on the skin and different electrical pulse rates and intensities are used to stimulate the area. Low-frequency TENS (also referred to as acupuncture-like TENS) usually consists of pulses delivered at 1 to 4 Hz at high intensity, so they evoke visible muscle fiber contractions. High-frequency TENS (conventional TENS) usually consists of pulses delivered at 50 to 120 Hz at a low intensity, so there are no muscle contractions.
  • McKenzie – A system of assessment and management for all musculoskeletal problems that uses classification into non-specific mechanical syndromes. Assessment involves the monitoring of symptomatic and mechanical responses during the use of repeated movements and sustained postures
  • Neuroreflexotherapy – Temporary implantations of epidermal devices into trigger points at the site of each subject’s clinically involved dermatomes on the back and into referred tender points in the ear.
  • Traction – Traction performed by utilizing the patient’s own body weight (for example by suspension via the lower limb) or through movement.
  • Intra-Discal Electrothermal Therapy (IDET) – Use of a heating wire passed through a hollow needle into the lumbar disc intended to seal any ruptures in the disc.
  • Prolotherapy – Injections of irritant solutions to strengthen lumbosacral ligaments.
  • The Back Book – A widely used advice booklet for people with back pain.
  • Psychological treatment – Psychological treatments include a range of talking therapies including both psychotherapy and counseling there a several different broad psychological approaches, including, for example, cognitive-behavioral therapy (CBT). The focus of these treatments is usually on health promotion rather than treating specific disorders
  • Counseling – Counselling takes place when a counselor sees a client in a private and confidential setting to explore a difficulty the client is having, distress they may be experiencing or perhaps their dissatisfaction with life, or loss of a sense of direction and purpose. It is always at the request of the client as no one can properly be ’sent’ for counseling.


  • Analgesics – with or without paracetamol may improve pain and function compared with placebo. However, long-term use of NSAIDs or opioids may be associated with well-recognized adverse effects.
  • Non-steroidal anti-inflammatory drugs – (NSAIDs) may be more effective than placebo at improving pain intensity in people with chronic low back pain. Nonsteroidal anti-inflammatory drugs were again the first-line pharmacologic agents recommended followed by tramadol and duloxetine as the second-line treatments.
  • Antidepressants  – decrease chronic low back pain or improve function compared with placebo in people with or without depression. Antidepressants such as tricyclic antidepressants and SNRI’s, topical analgesics, muscle relaxers, N-methyl-d-aspartate (NMDA) receptor antagonists, and alpha 2 adrenergic agonists are also the most effective pharmacological therapies.
  • Muscle Relaxant – Benzodiazepines may improve pain, but studies of non-benzodiazepine muscle relaxants have given conflicting results.
  • Gabapentin –The initial treatment of neuropathic pain and chronic back pain is often with gabapentin or pregabalin It is Considere’s most effective treatments are in general recommended in chronic low back pain. They are indicated for postherpetic neuralgia, diabetic neuropathy, and mixed neuropathy.
  • Tricyclic antidepressant (TCA) – A type of drug that can be used to treat back pain –this use is different from its action in treating depression, which usually requires a much higher dose. Examples include amitriptyline and imipramine
  • Epidural corticosteroid injections – or local injections with corticosteroids and local anesthetic improve chronic low back pain treatment in people without sciatica. Facet-joint corticosteroid injections may be more effective than placebo at reducing pain.
  • Epidural glucocorticoid injections – are beneficial for up to three months in duration in patients with acute lumbar radiculopathy. This benefit is modest yet clinically significant in the short-term. If a patient has not improved after six weeks of conservative management, they would be eligible for an epidural glucocorticoid injection.
  • Oral systemic steroids tablet – are often prescribed for acute low back pain, and chronic low back pain although there is limited evidence to support their use. It is basically used to remove nerve-related inflammation, edema, hematoma.
  • The serotonin-norepinephrine reuptake inhibitor (SNRI) – duloxetine is useful in treating chronic pain, osteoarthritis, and the treatment of fibromyalgia. Furthermore, the efficacy of duloxetine in the treatment of comorbid depression is comparable to other antidepressants. Venlafaxine is an effective treatment for neuropathic pain, as well. A TCA can also be utilized, such as nortriptyline. TCA medications may require six to eight weeks to achieve their desired effect.
  • Topical lidocaine and ointment – is a useful treatment for neuropathic pain and allodynia as in postherpetic neuralgia.  Separately, topical capsaicin cream is an option for chronic neuropathic or musculoskeletal pain unresponsive to other treatments.
  • Opioids – are considered a second-line option; however, they may be warranted for pain management for patients with severe persistent pain or neuropathic pain secondary to malignancy. Opioid therapy should only start with extreme caution for patients with chronic back pain and musculoskeletal pain. Side effects of opioids are significant and frequent and may include opioid-induced hyperalgesia, constipation, dependence, and sedation.
  • Buprenorphine – Patients with chronic pain who meet the criteria for the diagnosis of opioid use disorder should receive the option of buprenorphine to treat their chronic pain. Buprenorphine is a considerably better alternative for patients with very high daily morphine equivalents who have failed to achieve adequate analgesia. It is a considerably better alternative for patients with very high daily morphine equivalents who have failed to achieve adequate analgesia.
  • Botulinum toxin – has also demonstrated effectiveness in the treatment of postherpetic neuralgia. The use of cannabis is also an area of interest in pain research. There is some evidence that medical marijuana can be an effective treatment of neuropathic pain and chronic low back pain, while the evidence is currently limited in treating other types of chronic pain.

Surgical Treatments

When other therapies fail, surgery may be considered to relieve pain caused by worsening nerve damage, serious musculoskeletal injuries, or nerve compression. Specific surgeries are selected for specific conditions/indications. However, surgery is not always successful. It may be months following surgery before the person is fully healed and there may be permanent loss of flexibility. Surgical options include:

  • Vertebroplasty and kyphoplasty – for fractured vertebrae are minimally invasive treatments to repair compression fractures of the vertebrae caused by osteoporosis. Vertebroplasty uses three-dimensional imaging to assist in guiding a fine needle through the skin into the vertebral body, the largest part of the vertebrae. Glue-like bone cement is then injected into the vertebral body space, which quickly hardens to stabilize and strengthen the bone and provide pain relief. In kyphoplasty, prior to injecting the bone cement, a special balloon is inserted and gently inflated to restore height to the vertebral structure and reduce spinal deformity.
  • Spinal laminectomy – (also known as spinal decompression) is done when a narrowing of the spinal canal causes pain, numbness, or weakness. During the procedure, the lamina or bony walls of the vertebrae are removed, along with any bone spurs, to relieve pressure on the nerves.
  • Discectomy and microdiscectomy – involve removing a herniated disc through an incision in the back (microdiscectomy uses a much smaller incision in the back and allows for a more rapid recovery). Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.
  • Foraminotomy – is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can narrow the space where the spinal nerve exits and press on the nerve. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve pressure on the nerve.
  • Nucleoplasty – also called plasma disc decompression (PDD), is a type of laser surgery that uses radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the disc, reducing its size and relieving pressure on the nerves.
  • Radiofrequency denervation – uses electrical impulses to interrupt nerve conduction (including pain signaling). Using x-ray guidance, a needle is inserted into a target area of nerves and the region is heated, which destroys part of the target nerves and offers temporary pain relief.
  • Spinal fusion – is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.
  • Artificial disc replacement – is an alternative to spinal fusion for treating severely damaged discs. The procedure involves removing the disc and replacing it with a synthetic disc that helps restore height and movement between the vertebrae.
  • Interspinous spacers – are small devices that are inserted into the spine to keep the spinal canal open and avoid pinching the nerves. It is used to treat people with spinal stenosis.

Implanted nerve stimulators

  • Spinal cord stimulation – uses low-voltage electrical impulses from a small implanted device that is connected to a wire that runs along the spinal cord. The impulses are designed to block pain signals that are normally sent to the brain.
  • Dorsal root ganglion stimulation – also involves electrical signals sent along a wire connected to a small device that is implanted into the lower back. It specifically targets the nerve fibers that transmit pain signals. The impulses are designed to replace pain signals with a less painful numbing or tingling sensation.
  • Peripheral nerve stimulation – also uses a small implanted device and an electrode to generate and send electrical pulses that create a tingling sensation to provide pain relief.

Rehabilitation programs

Rehabilitation teams use a mix of healthcare professionals from different specialties and disciplines to develop programs of care that help people live with chronic pain. The programs are designed to help the individual reduce pain and reliance on opioid pain medicines. Programs last usually two to three weeks and can be done on an in-patient or out-patient basis.


Types of exercise that have proven effective include the following:

  • Special programs – consisting of exercises to strengthen and stabilize the deep abdominal (tummy), back and pelvic muscles, as well as endurance training and exercises to stretch the muscles in the calves, hips and thighs.
  • Pilates – A total body workout in which strengthening the deep core muscles is key.
  • Tai chi – Originally an Asian martial art, tai chi is now practiced with slow, flowing movements. It can improve your balance and coordination skills, strengthen your muscles, and is said to help you relax your body and mind.
  • Yoga – An ancient Indian practice that aims to improve your body awareness and health. Yoga typically involves getting into various positions or carrying out certain sequences of movements that aim to promote strength and flexibility, body awareness, and a good posture.
  • Going on walks – Initial research suggests that going on a walk or brisk walking (Nordic walking) can help relieve back pain if done regularly – for instance, every two days for 30 to 60 minutes.
  • Alexander Technique – The Alexander Technique is a taught self-care discipline that enables an individual to recognize, understand, and avoid habits adversely affecting muscle tone, coordination, and spinal functioning. Priority is given to habits that affect freedom of poise of the head and neck and that lead to stiffening and shortening of the spine, often causing or aggravating the pain.
  • Chiropractic treatment – The diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the functions of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation. (World Federation of Chiropractic 2001)

A doctor or physiotherapist can help you to find a suitable type of exercise that is tailored to your situation and that you enjoy. People who have medical problems often find it helpful to have a course instructor or trainer with the appropriate experience.

Passive treatments

Passive treatments, on the other hand, are carried out by other people – because you can’t do them yourself or because they don’t involve being active yourself. These treatments include the following:

  • Acupuncture
  • Electrotherapy
  • Kinesiology taping
  • Short-wave diathermy
  • Laser therapy
  • Magnetic field therapy
  • Manual therapy techniques such as manipulation and mobilization of the spine
  • Massages
  • Osteopathic treatments
  • Applying heat or cold
  • Therapeutic ultrasound
  • Traction

The national guidelines consist of a collection of recommendations to improve the care of people with back pain. They were developed by several medical societies in Germany, based on current research.

  • Acupuncture is a traditional Chinese treatment in which thin needles are inserted into specific points on the skin. According to traditional beliefs, the needles influence the flow of energy through the body when they are placed at points along the energy pathways (meridians). This is thought to activate the body’s own healing powers. But these energy pathways haven’t been proven to exist. Research has shown that it doesn’t matter where exactly you insert the needles and whether they actually enter the skin or not.
  • There aren’t many good-quality studies on acupuncture for the treatment of chronic back pain. The best study concluded that acupuncture wasn’t more effective than “fake” acupuncture. Other studies found that acupuncture was slightly better at relieving the pain. But the effect was only small and didn’t last long.
  • Inserting the acupuncture needles sometimes causes minor bleeding or bruising. To avoid infection, it is important to use sterile disposable needles. The risk of serious side effects is low.
  • Transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) are types of electrotherapy. These treatments use specialist equipment to trigger electrical impulses in the nervous system. This is done to stop pain signals being sent to the brain and to stimulate the production of endorphins, the body’s own pain-relieving hormones. TENS involves placing electrodes on the skin to send electrical impulses through the skin (transcutaneously). In PENS, the electrical impulses are transmitted through acupuncture needles inserted into the skin (percutaneously). Inferential current therapy is another technique that works in a similar way to TENS.
  • Electrotherapy hasn’t been proven to relieve chronic back pain. In PENS, the small punctures in the skin may lead to minor bleeding or an infection.
Mobilization and manipulation of the spine
  • Mobilization and manipulation are both types of manual therapy (“manual” comes from the Latin word for “hand”: manus). In mobilization, the therapist slowly moves the joint within its natural range of movement. Manipulation therapy, on the other hand, involves using short, sharp movements to push a joint beyond its normal range of movement.
  • This type of sudden manipulation is also known as a chiropractic adjustment. Popping or cracking sounds may be heard during the procedure. These sounds occur when small bubbles of gas in the joints burst, just like when people crack their knuckles. It’s not exactly clear how these approaches are meant to work. Some of the current theories involve the release of muscle tension, the “unsticking” of tissue that is stuck together, and the realignment of certain joint structures.
  • There are only a few good-quality studies on the manipulation and mobilization of the spine for the treatment of chronic back pain. Further research is needed in order to properly assess the effectiveness of these treatments.
  • Manual therapy can sometimes have side effects such as sore muscles, cramping, and temporary stiff joints or pain. More serious complications of joint manipulation, such as broken bones or partial paralysis, are very rare. They could occur if, for instance, someone has osteoporosis or if the manipulation leads to a slipped disk or makes an existing slipped disk worse.
  • Massages are a traditional way of treating back pain. They are meant to relax your muscles, reduce painful muscle tension, and increase your general sense of wellbeing.
  • There are different types of massage. Common techniques include traditional (Swedish) massage, Thai massage, and acupressure. The methods differ in terms of the type of hand movements that are used and which parts of the body are massaged. They also vary in the amount of pressure applied, and whether the massage therapist uses their hands, fingertips, or special tools.
  • Massages can relieve chronic back pain a little, for a short time, but they don’t have a lasting effect. Depending on how much pressure is applied to the affected area, the massage might be painful or you might feel sore afterward. Some people are allergic to massage oil, which can cause things like rashes.
  • Osteopathy is a type of alternative treatment. It is based on the idea that all of the body’s structures and functions influence each other. This means that problems and diseases in one joint or organ are thought to have an effect on other parts of the body. Connective tissue is considered to be particularly important in osteopathy because it connects the body’s different physical structures and organs. There is no scientific proof that this theory is true, though.
  • In osteopathy, therapists use nothing but their hands when performing physical examinations and treatments. The therapist first feels for areas of limited mobility and areas of tension in the body, as well as other kinds of tissue changes. Then they apply various stretching techniques, massage approaches, and hand movements to help with these problems. One type of osteopathic treatment is known as “muscle energy techniques.” The aim of these approaches is to release areas of physical tension by tensing the muscles and stretching. Research on osteopathic treatments for back pain has produced contradictory results. There is no proof that muscle energy techniques work.

In Germany, the job title “osteopath” isn’t protected and doesn’t require specific training.

Other treatments
  • Other treatments that haven’t been proven to help reduce back pain include kinesiology taping, short-wave diathermy, laser therapy, magnetic field therapy, and therapeutic ultrasound.

Can back pain be prevented?

Recurring back pain resulting from improper body mechanics may be prevented by avoiding movements that jolt or strain the back, maintaining correct posture, and lifting objects properly. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object), vibration, repetitive motion, and awkward posture.
Recommendations for keeping one’s back healthy

  • Exercise regularly to keep muscles strong and flexible. Consult a physician for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and abdominal muscles.
  • Maintain a healthy weight and eat a nutritious diet with a sufficient daily intake of calcium, phosphorus, and vitamin D to promote new bone growth.
  • Use ergonomically designed furniture and equipment at home and at work. Make sure work surfaces are at a comfortable height.
  • Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some lumbar support. Put your feet on a low stool or a stack of books when sitting for a long time.
  • Wear comfortable, low-heeled shoes.
  • Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.
  • Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting.
  • Quit smoking. Smoking reduces blood flow to the lower spine, which can contribute to spinal disc degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to heavy smoking also may cause back pain.

Anatomy of The Low Back

The lumbar spine consists of five vertebrae (L1–L5). The complex anatomy of the lumbar spine is a combination of these strong vertebrae, linked by joint capsules, ligaments, tendons, and muscles, with extensive innervation. The spine is designed to be strong since it has to protect the spinal cord and spinal nerve roots. At the same time, it is highly flexible, providing for mobility in many different planes.

The mobility of the vertebral column is provided by the symphyseal joints between the vertebral bodies, with an IVD in between. The facet joints are located between and behind adjacent vertebrae, contributing to spine stability. They are found at every spinal level and provide about 20% of the torsional (twisting) stability in the neck and low back segments . Ligaments aid in joint stability during rest and movement, preventing injury from hyperextension and hyperflexion. The three main ligaments are the anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), and ligament flavum (LF). The canal is bordered by vertebral bodies and discs anteriorly and by laminae and LF posteriorly. Both the ALL and PLL run the entire length of the spine, anteriorly and posteriorly, respectively. Laterally, spinal nerves, and vessels come out from the intervertebral foramen. Beneath each lumbar vertebra, there is the corresponding foramen, from which spinal nerve roots exit. For example, the L1 neural foramina are located just below the L1 vertebra, from where the L1 nerve root exits.

IVDs are located between vertebrae. They are compressible structures able to distribute compressive loads through osmotic pressurization. In the IVD, the annulus fibrosus (AF), a concentric ring structure of organized lamellar collagen, surrounds the proteoglycan-rich inner nucleus pulposus (NP). Discs are avascular in adulthood, except for the periphery. At birth, the human disc has some vascular supply but these vessels soon recede, leaving the disc with little direct blood supply in the healthy adult . Hence, the metabolic support of much of the IVD is dependent on the cartilaginous endplates adjacent to the vertebral body. A meningeal branch of the spinal nerve, better known as the recurrent sinuvertebral nerve, innervates the area around the disc space .

The lumbar spine is governed by four functional groups of muscles, split into extensors, flexors, lateral flexors, and rotators. The lumbar vertebrae are vascularized by lumbar arteries that originate in the aorta. Spinal branches of the lumbar arteries enter the intervertebral foramen at each level, dividing themselves into smaller anterior and posterior branches . The venous drainage parallels the arterial supply .

Typically, the end of the spinal cord forms the conus medullaris within the lumbar spinal canal at the lower margin of the L2 vertebra . All lumbar spinal nerve roots stem from the connection between the dorsal or posterior (somatic sensory) root from the posterolateral aspect of the spinal cord and the ventral or anterior (somatic motor) root from the anterolateral aspect of the cord . The roots then flow down through the spinal canal, developing into the cauda equina, before exiting as a single pair of spinal nerves at their respective intervertebral foramina. Cell bodies of the motor nerve fibers can be found in the ventral or anterior horns of the spinal cord, whereas those of the sensory nerve fibers are in the dorsal root ganglion (DRG) at each level. One or more recurrent meningeal branches, known as the sinuvertebral nerves, run out from the lumbar spinal nerves. The sinuvertebral nerve, or Luschka’s nerve, is a recurrent branch created from the merging of the grey ramus communicans (GRC) with a small branch coming from the proximal end of the anterior primary ramus of the spinal nerve. This polisegmentary mixed nerve directly re-enters the spinal canal and gives off ascending and descending anastomosing branches comprising both somatic and autonomic fibers for the posterolateral annulus, the posterior vertebral body, and the periosteum, and the ventral meninges , . The sinuvertebral nerves connect with branches from radicular levels both above and below the point of entry, in addition to the contralateral side, meaning that localizing pain from the involvement of these nerves is challenging . Also, the facet joints receive two-level innervation comprising somatic and autonomic components. The former conveys a well-defined local pain, while the autonomic afferents transmit referred pain.


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